Drifting… from the plan: evidence-based treatment and therapist drift

Yesterday I looked at some of the points made by Waller in his paper on Evidence-based treatment and therapist drift (2009) when I discussed times when therapists contribute to poor outcomes from treatment. I started looking at this when I was thinking about the distinction between ‘teaching’, ‘education’ or ‘information’ and helping someone reconceptualise their pain and start to take steps to manage it.

Sometimes the ‘therapy’ is given the blame for the person not managing their situation. Sometimes the ‘patient’ is identified as ‘the problem’, they’re not doing the therapy, not motivated, have another agenda. But it’s not so often we think of the way that we’re doing the treatment as part of the problem.

Waller identifies some of the psychological factors that contribute to therapists not doing therapy as well as they might.

The first of these are our thoughts as therapists. This can range from our own positive attributional tendencies – we like to think it’s our therapy that is successful, and non-treatment factors that make it unsuccessful. So it’s the relaxation training that has helped the person cope better, while the person failing to use relaxation in real life is the ‘patient’s problem transferring learning’.

We also have our schemas – we may have preferences for certain aspects of treatment, and have difficulty identifying evidence that shows that specific treatment isn’t working. Waller identifies motivation as something that neither clinicians or patients are good at identifying levels of motivation. How this works is that we are likely to think someone is motivated because they say so, but when they don’t follow through by missing sessions, or not carrying out home-based learning, we might ignore or excuse this.

Our emotions, too, can play a part. Sometimes we can feel anxious about increasing a person’s pain – what if they blame us? What if we’ve done something wrong? Sometimes we can feel elated when someone makes a minor change but fails to make more major or important changes.

Our behaviours, what we do, are also influenced by two main factors – the context such as responding to workplace demands so that we don’t have enough time to plan or reflect between patients – and our own safety behaviours such as avoiding working with patients on behavioural change (because it’s hard work, gets us out of our offices, and means setting up situations where patients will experience more distress in the short-term even though its more effective in the long term).

I’ve thought about this a lot – and I recognise too, that often we’re not given enough time within a contract to work on assessment. We’re asked to develop a treatment plan without adequate time to develop a good formulation. Or we’re asked to consider only one or two areas to monitor as outcomes, when other areas are equally important.

Despite this, the areas we do know can be influenced by our own biases can be identified as part of supervision – then we can find ways to counter these. Provided that we and our supervisors are aware of them.

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